Pre-authorized Payment Agreement

Exhibit C
Hawaii Information
Pre-authorized Payment Agreement
Please select one of the payment cycles below
… Annually
… Semi-Annually
… Quarterly
MLS subscription fee schedule: Quarterly-Assessed each July 1st, October 1st, January 1st and April 1st; Semi-Annually- Assessed each January 1st
and July 1st; Annually- Assessed each July 1st. Payments are due by the 1st day of each billing period.
Please select and complete only one payment method option below
… Option 1 – Charge My Credit Card (Please select one of the following credit card types.)
… Visa
… MasterCard
Acct#: __________ - ___________ - ___________ - ___________
Exp Date:_______/_________
Cardholder Signature: X_____________________________________________________________________ Date: _________________________
Please print Cardholder’s Full Name (as it appears on the credit card):_________________________________________________________________
If the above credit card is to be used to pay for the fees of a subscriber other than the cardholder, please provide the name of the subscriber below.
Please print Subscriber’s Full Name:____________________________________________________________________________________________
… Option 2 – Debit My Bank Account
(Please select type of account) … Checking (Attach a copy of a voided check) … Savings (Attach a copy of deposit slip)
Name of Bank:________________________________________________________ Branch:______________________________________________
Bank Address:______________________________________________________________________________________________________________
Street Address
Zip Code
… Option 3 – Payment by Check
If paying by check, please mail your check made payable to Hawaii Information Service and this form to the address below by the
billing due date.
Please note that a $25.00 service fee may be assessed in the event of returned checks or credit card denial or if changes to payment method or
cycle are made after the billing has been processed. Fees not paid when due may result in the assessment of late fees and/or the suspension or
termination of service.
… Option 4 – Annual Office Billing (This option is only available to PBS, PAS or DR, if he/she is paying for all of his/her office Associate and
Support Subscribers’ subscription fees.)
Please print PBS/PAS’s Name: ___________________________________________________________________________________
Please Print PBS/PAS’s Firm’s Name: ______________________________________________________________________________
Principal Broker/Appraiser Subscriber’s Signature: X____________________________________________ Date________________
Please complete the following information and sign the agreement below
Please print your Name: ____________________________________________________________________________________________________
Last Name
First Name
Middle Initial(s)
Name of your Firm/Office/Employer: _________________________________________________________________________________________
Your Billing Address:________________________________________________________________________________________________________
Street Address
Zip Code
Your Email Address (Required):_______________________________________________________________________________________________
I authorize Hawaii Information Service (HIS) to keep my signature on file and to charge my VISA, MasterCard or debit my
checking/savings account for all fees including, but not limited to set-up fees, subscription fees (assessed in advance no more
frequently than quarterly), training or class fees, and the cost of any other products or services I order from HIS. (See Exhibit B,
Schedule of Fees and Charges)
I understand that this form is valid as long as I am a subscriber of HIS and/or have any outstanding amounts due to HIS. To avoid
service interruption, I will notify HIS of any change in my credit card, checking or savings account. Furthermore, I understand that
charges will continue until HIS is otherwise notified in writing. I agree to abide by the HIS Subscriber License and Access Agreement,
including, but not limited to Section 7(c), which states: “No refunds. HIS need not refund or pro-rate fees in the event of termination
or suspension of this Agreement.” I also agree that I will comply with the current rules of the service.
Notice: If you are a PBS or PAS, you will be copied on each notice of non-payment of subscription, service or rules violation fees by your
Associate or Support Subscribers. Their failure to pay fees may affect service to you and your office. In the event that our efforts to collect fees
from one of your affiliated subscribers are unsuccessful, you will be notified and offered an opportunity to pay for your affiliated subscriber’s
fees on his/her behalf to avoid service to you and your office from being interrupted or terminated. Please report changes to your office roster
to HIS within 24 hours, including any changes in licensure status for subscribers affiliated with your office. You are responsible for the fees
charged to your associate and support subscribers as long as they are on your roster.
Subscriber’s Signature X___________________________________________________________________________ Date___________________
If Subscriber is not a Principal Broker Subscriber(PBS) or Principal Appraiser Subscriber(PAS), the PBS or PAS must sign below.
Principal Broker/Appraiser Subscriber’s Signature: X____________________________________________ Date________________
Please email, fax or mail this form to Hawaii Information Service to activate your service. Allow 48 hours for activation, excluding weekends and holidays. Email
to [email protected], Fax to 1-888-628-3121 from Neighbor Islands or 808-536-6499 from Oahu, or Mail to Hawaii Information Service, 680
Iwilei Road #670, Honolulu, HI 96817.
Revised: 2015-05-15